Ametros’ CareGuard service supports individuals in efficiently managing their settlement funds. With CareGuard, the MSA funds are securely held in an interest-bearing account under the injured party’s name. Ametros acts as the custodian, overseeing all aspects of fund management.

Benefits of CareGuard Service

• Professional Administration: CareGuard takes care of everything for the injured party, ensuring hassle-free fund management.
• Ease of Use with the CareGuard Card: The injured party gets a CareGuard card, functioning like a traditional insurance card, allowing them to avail of group purchasing discounts at doctors or pharmacies.

Simplified Medical Payments and Compliance

• Streamlined Bill Payments: CareGuard handles all medical bills for the injured party, ensuring Medicare compliance by managing all required reporting.
• Flexibility in Choosing Healthcare Providers: The injured party can select any doctor or pharmacy without the need for utilization reviews.

Dedicated Support Team

Ametros offers a team of Care Advocates ready to assist injured parties in coordinating their care, ensuring they receive the best possible service and support.

Additional Information

For more detailed insights into how Ametros and CareGuard services operate, please refer to the WCMSA Reference Guide.

The Centers for Medicare & Medicaid Services (CMS) strongly recommend professional administration for a Medicare Set-Aside (MSA). This service helps alleviate the burden on the injured party by managing funds, ensuring proper reporting to CMS, and tracking expenses.

Importance of Professional Administration

Professional administration is recommended due to the complex rules and regulations involved in managing a Medicare Set-Aside account. The CMS updated their Workers’ Compensation Medicare Set-Aside (WCMSA) Reference Guide in July 2017 to emphasize this, stating in Section 17.1: “It is highly recommended that settlement recipients consider the use of a professional administrator for their funds.”

Benefits of Professional Administration 

• Compliance Management: Professional administrators ensure adherence to all relevant rules, reducing the risk of mismanagement that could jeopardize Medicare benefits.
• Fund Tracking: They help track the funds, making it easier for the injured party to manage their settlements efficiently.
• CMS Reporting: Accurate and timely reporting to CMS is handled, ensuring continued eligibility for Medicare benefits.

How Ametros Helps

At Ametros, we strive to offer a seamless process for protecting Medicare benefits through our professional administration service, CareGuard. With CareGuard, the injured party does not have to handle bills or worry about Medicare reporting, ensuring their Medicare benefits remain intact upon settlement.

For further details about MSAs and professional administration, consult the WCMSA Reference Guide. This guide provides comprehensive information on the best practices for effectively managing a Medicare Set-Aside account.

Professional administrators play a crucial role in extending settlement funds by leveraging their expertise and networks. They secure potential discounts through their provider and pharmacy networks and negotiate with service providers to maximize funds.

Expertise of Professional Administrators 

Professional administrators are skilled in ensuring medical funds are efficiently managed. Their expertise includes:

• Securing appropriate billing with correct ICD-9 and 10 codes
• Adhering to applicable fee schedules 
• Negotiating fees to enhance fund longevity 

Potential Discounts and Negotiations 

One of the primary ways professional administrators extend settlement funds is through negotiating discounts. By working closely with service providers and utilizing established networks, they can significantly reduce medical expenses.

How Does Fee Negotiation Affect Settlement Funds? 

Fee negotiation is a critical strategy used by professional administrators. It involves:

• Engaging with service providers to discuss fee reductions
• Ensuring that all charges align with negotiated pricing
• Monitoring ongoing expenses to maintain fund efficiency

Injured parties managing Medicare Set-Asides (MSAs) must adhere to certain rules: 

• Use MSA funds exclusively for Medicare-covered treatments related to the injury.
• Maintain funds in a separate, interest-bearing bank account.
• Keep and organize all related bills and receipts.
• Report expenditures to CMS annually or when funds are depleted.

Key Rules for MSA Administration 

Adhering to MSA administration regulations is crucial. Here’s a breakdown of important points to remember: 

• Medicare-Covered Expenses: The primary rule is that MSA funds can only be used for expenses that Medicare covers, directly pertaining to the injury. This helps ensure continued Medicare coverage when MSA funds deplete.

• Dedicated Bank Account: MSA funds should be stored in a separate, interest-bearing account to prevent commingling with other funds and simplify accounting.

• Record Keeping: Maintaining accurate records is essential. This includes: 
  • Copies of all bills and receipts.
  • Detailed reports of every expense funded by the MSA. 

These records must be submitted to the Centers for Medicare and Medicaid Services (CMS) in an annual attestation. 

Reporting and Compliance 

• Annual Reporting to CMS Regular reporting is mandatory to prove that MSA funds are used correctly. Failing to do so could lead to Medicare denial of injury-related treatments. 

• Depletion and Exhaustion Forms In cases where MSA funds are depleted: 
  • File a temporary depletion form for future annuity payments.
  • Submit a permanent exhaustion form if funds are permanently exhausted.

Professional Administration 

CMS highly recommends using professional administrators, like Ametros, to ensure proper management and reporting of MSA accounts. This can mitigate risks related to compliance and ensures government reports are accurate. 

Further Details and Resources 

For comprehensive guidance, refer to CMS' WCMSA Reference Guide and Self Administration Toolkit. These resources offer in-depth information on navigating MSA administration, ensuring compliance, and safeguarding your Medicare benefits.

What if I want to self-administer my Medicare Set-Aside?

Injured parties have the option to self-administer their Medicare Set-Aside (MSA). While Medicare does not recommend this approach, it is possible for individuals to manage their own accounts.

Self-Administration Toolkit

For those choosing to self-administer, there is a 31-page Self Administration Toolkit available. It is essential for the injured party to become acquainted with this toolkit to effectively manage their MSA funds.

Importance of Legal Familiarity

Besides the toolkit, it’s crucial for the individual to understand the WCMSA Reference Guide and the Federal Medicare Secondary Payer Act (42 U.S.C. §1395 et seq), which are subject to periodic amendments.

Using Ametros’ Amethyst Service for Self-Administration

Ametros provides a service known as Amethyst, which aids individuals in self-administering their MSA with added support. This service links directly to the injured party’s personal bank account, offering the convenience and control of their settlement funds. With the Amethyst card, functioning similarly to a traditional insurance card, individuals can easily manage their medical funds while benefiting from support and savings — akin to what is offered by CareGuard.

Why Consider Professional Administration?

Many parties opt for professional administration to avoid potential pitfalls and to ensure compliance with Medicare guidelines. For further reading and detailed information about self-administration, you can explore additional resources in the WCMSA Reference Guide and other relevant documents.

For comprehensive guidance and the most up-to-date information, it is recommended to review the latest WCMSA Reference Guide and consult with professionals who can provide personalized advice based on current regulations.

Why is professional administration recommended for an Medicare Set-Aside?

What happens to unused Medicare Set-Aside funds?

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Once your Medicare Set-Aside (MSA) account is established, you can only use it to cover medical treatment or prescription drugs related to your workers' compensation (WC) claim. This spending is subject to Medicare guidelines, even if you're not yet enrolled in Medicare.

Is it illegal to spend Medicare Set Aside money?

No, however, spending MSA funds on non-covered items may lead to denied Medicare claims until proper usage of the full MSA amount is demonstrated. In other words: funds in an MSA are specifically allocated for treatments associated with the work-injury covered by Medicare. These funds can only be used for medical treatment or prescription drugs related to your workers' compensation claim.

Can I use MSA funds for over-the-counter medications and medical supplies?

Generally yes, but only if they're prescribed by a doctor or are directly related to your workers' compensation injury. Keep detailed receipts and documentation to prove the connection to your work-related condition.

• What can I use my Medicare Set Aside account on?

What will happen if I spend my MSA funds on other expenses?

When funds from your MSA account are utilized incorrectly, Medicare may deny related claims. The account administrator must show appropriate use equal to the MSA amount for claim acceptance.

Detailed Guidance and Reference

For more detailed information, you can consult the Self-Administration Toolkit for Workers’ Compensation Medicare Set-Aside Arrangements and the Workers’ Compensation Medicare Set-Aside Reference Guide.

What is a Medicare Set-Aside?

What is a Medical Cost Projection?

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The injured party can use their Medicare Set-Aside (MSA) funds on Medicare-approved expenses directly related to their injury. Your MSA account can only be used to pay for medical treatment or prescription drugs that are both related to your workers' compensation injury and would be covered by Medicare. This applies even if you're not yet a Medicare beneficiary.

Allowed expenses for MSA funds

All allowed expenses must be primarily for medical care rather than general health or cosmetic purposes and must be related to the injury that necessitated the MSA. Expenses that are usually allowed include:

1. Medical care: Doctor visits, hospital services, surgeries, and lab work.
2. Prescription medications: All medications prescribed by a physician.
3. Durable medical equipment and supplies: Crutches, wheelchairs, blood sugar test kits.
4. Physical therapy and rehabilitation services.
5. Hearing aids and batteries.
6. Dental care: Cleanings, fillings, extractions, dentures, and orthodontia.
7. Vision care: Eye exams, glasses, contact lenses, and laser eye surgery.
8. Mental health services: Therapy, psychiatric care, and addiction treatment.
9. Preventive care: Screenings, annual physicals, and immunizations.
10. Qualified long-term care services.
11. Travel expenses essential for medical care (gas mileage, parking, tolls).

What expenses are not allowed to be paid from an MSA account?

It's important to note that MSA funds cannot be used for any other expenses other than the Medicare-approved items and services connected to the injury. Misuse of funds can lead to penalties or affect future Medicare coverage.

1. Health insurance premiums (with certain exceptions like COBRA, long-term care insurance, or health insurance while receiving unemployment benefits)
2. Cosmetic procedures that aren't medically necessary (such as cosmetic surgery, teeth whitening, etc.)
3. General health products like vitamins, supplements, or toothpaste (unless specifically prescribed for a medical condition)
4. Non-prescription medications (except insulin and some OTC items with a doctor's prescription)
5. Expenses incurred before your MSA was established
6. Gym memberships or fitness programs (unless specifically prescribed by a doctor for a medical condition)
7. Expenses reimbursed by other insurance
8. Funeral expenses
9. International medical treatments (in most cases)

Managing MSA expenses effectively

If you are self-administering your MSA, it’s important to carefully review healthcare provider bills to ensure they are only for items and services that are both related to your workers' compensation claim and covered by Medicare before paying. Proper management of your MSA funds ensures that once your account is appropriately exhausted, Medicare will pay for future treatments.

Managing MSA expenses yourself can be complicated. We’re here to help – with CareGuard, you'll never deal with a medical bill alone, and our experts will file any necessary Medicare Set Aside reporting on your behalf.

Additional Guidance on MSA Accounts

For more detailed information about managing and using MSA funds in accordance with Medicare guidelines, consult the WCMSA Reference Guide.

Yes, CMS requires all Medicare Set Aside funds to be stored in a separate, interest-bearing account to prevent commingling with other funds and simplify accounting.

What are the CMS requirements for managing Medicare Set Aside bank accounts?

• Use MSA funds exclusively for Medicare-covered treatments related to the injury.
• Maintain funds in a separate, interest-bearing bank account.
• Keep and organize all related bills and receipts.
• Report expenditures to CMS annually or when funds are depleted.

How are funds deposited into my Medicare Set Aside account?

• Lump sum settlements: funds will only be deposited into your account in one lump sum.
• Structured settlements or annuity payments: there may be an initial deposit, followed by periodic deposits that often occur annually.

What is the best way to comply with Medicare Set Aside bank account requirements?

Due to the complexity of administering and managing a Medicare Set Aside account, CMS strongly recommends that injured parties use a professional administrator. Using professional administration means you never have to worry about compliance with Medicare rules, process bills, maintaining records or handling CMS reporting.

Learn more about Ametros’ professional administration service, CareGuard

CareGuard is a leading professional administration service that helps manage your future medical funds following a workers' compensation or liability settlement. Our goal is to make your post-settlement life easier by saving you money on doctor's visits, prescriptions, medical equipment, and more, all while coordinating your care. With CareGuard, you’ll never deal with a medical bill alone, and our experts will manage any necessary Medicare Set Aside reporting on your behalf.

Learn more about CareGuard

In most situations, the entire amount received from a personal physical injury settlement is non-taxable. Consequently, your Medicare Set-Aside (MSA) funds, as part of that settlement, are also not taxed when you initially receive them.

Tax Responsibilities for Interest on MSA Funds

The injured party must pay taxes on any interest earned from their MSA funds. Generally, if the interest earned exceeds $10, the bank will issue a 1099-INT form to the injured party for use in their tax return. According to Medicare's guidelines, taxes on interest income can be paid from the MSA account itself.

Additional Tax Considerations 

• Interest income from MSA funds is taxable.
• Ensure to use your 1099-INT form provided by the bank during tax filing.

For any intricate details regarding taxation and Medicare guidelines, consider consulting a tax professional or referring to the IRS website on taxable income.

Funding Medicare Set-Aside Accounts 

A Medicare Set-Aside (MSA) can be funded through one of two methods:

• Lump-Sum Payment: A one-time payment to fund the entire MSA.
• Structured Settlement: Initial deposit (often called "seed" money) followed by regular annual payments.

Since each method has different benefits, reference the Self-Admin Toolkit, v1.3, sec. 3 for detailed guidance on managing these options.

Benefits of Annuity-Funded MSA

Choosing a structured settlement to fund an MSA provides distinct advantages. For Medicare beneficiaries, if funds are depleted temporarily in any year, Medicare reimburses MSA-covered healthcare treatments. This information is covered further in the Self-Admin Toolkit, v1.3, sec. 11.

Managing and Storing MSA Funds

It is critical to keep MSA funds in an interest-bearing account that is separate from other personal accounts. It's recommended by CMS to store funds in an FDIC-insured account without low-balance fees, providing easy check access. For more details, see Self-Admin Toolkit, v1.3, sec. 2 and the WCMSA Reference Guide, v.3.1, sec 17.2.

Appropriate Use of MSA Funds

To avoid potential issues with Medicare denying treatment, it is essential to use MSA funds solely for Medicare-covered treatments related to the initial injury. For further information, refer to the Self-Admin Toolkit, v1.3, sec. 4.

Administering Your Medicare Set-Aside

MSAs can be self-administered (if permitted by state law) or managed by a professional administrator. CMS advises that injured parties consider using a professional administrator for added protection. More about this is discussed in the WCMSA Reference Guide, v.3.1, sec 10.6.

Protecting MSA Funds with Professional Administration

Professional administration, such as services offered by Ametros, can shield MSA accounts from direct garnishments often requested by states. This additional layer of protection is advantageous compared to self-administration, ensuring compliance and security. A professional administrator can significantly decrease garnishment risks.

For detailed procedures and further reading, please consult the WCMSA Reference Guide and the Self-Admin Toolkit sections as mentioned.

For any related questions or further advice on managing your MSA funds, consider reaching out to a professional administrator or consulting the provided resources.

If you have a structured settlement and use up all the money in your MSA account before your next annual deposit arrives, your next steps depend on your Medicare status.

Handling an exhausted MSA if you are a current Medicare beneficiary

If you are a Medicare beneficiary, you should send an attestation letter to the Benefits Coordination & Recovery Center (BCRC) stating that your account is temporarily depleted. You can then bill Medicare for any additional expenses related to your workers' compensation injury until your next annual deposit is received.

This creates a situation where you will have alternating primary payers: first yourself through the MSA, then Medicare while your account is depleted, and then yourself again when your account receives its next funding. This alternating payment responsibility can be confusing for healthcare providers. It's important to clearly communicate with them about when they should bill Medicare instead of expecting payment from your MSA account.

If you have MSA funds to pay part of a bill but not all of it, it’s recommended you ask healthcare providers to send the entire bill to Medicare rather than paying it yourself.

Handling an exhausted MSA if you are NOT a Medicare beneficiary

If you are not yet a Medicare beneficiary when your account is temporarily depleted, you will need to use other insurance to pay for workers' compensation injury treatments until your MSA receives its next deposit. If you have no other insurance coverage, you will unfortunately have to pay out of pocket for these treatments until more funds are deposited into your account.

If you are self-administering your MSA, you can find more information about attestation in Self-Administration ToolKit v. 1.7

We’re Here to Help

With CareGuard, you're never deal with a medical bill alone. If you have a Medicare Set-Aside, CareGuard ensures full compliance by handling all necessary reporting to The Centers of Medicare and Medicaid Services (CMS), giving you peace of mind.

CareGuard also simplifies your care-related payments. Just present your CareGuard card at your doctor’s office or pharmacy, and we’ll handle the rest.

Please note: While CareGuard streamlines the billing process, there may be situations where members are responsible for paying a bill directly. In such cases, members can submit the invoice for reimbursement, as outlined in the Member Agreement provided at enrollment.

Learn more about CareGuard

When your Medicare Set-Aside (MSA) funds are exhausted, Medicare will begin to pay for covered items related to your injury, provided that you have properly managed and reported your MSA spending to Medicare. Additionally, you must be enrolled as a Medicare beneficiary. If these conditions are met, Medicare covers you just like any other beneficiary, including the applicable co-pays, coinsurance, and deductibles. 

Conditions for Medicare to Step In 

Proper Management of MSA Funds: If your MSA funds are depleted according to Medicare’s guidelines, and you've reported your spending correctly, Medicare will become the primary payer for your future medical expenses related to the injury. 

Requirements to Ensure Coverage 

To qualify for Medicare to cover your injury-related medical expenses after your MSA is exhausted: 

• Enrollment in Medicare: You must be enrolled during an enrollment period.
• Correct Management of MSA Funds: Adhering to Medicare’s rules for managing your MSA is crucial. 

Failure to correctly manage and report your MSA funds may result in a denial of coverage for injury-related care. Incorrect handling might jeopardize your future Medicare benefits. 

Steps if Coverage is Denied 

If your care is denied, you must replenish your MSA account for any unaccounted expenses and correct reporting to Medicare. It may be helpful to consult a professional administrator for assistance in managing your MSA effectively. 

For detailed information about the rules and proper management of your MSA, consider referring to the WCMSA Reference Guide. 

There is currently no policy that permits an individual with a Medicare Set-Aside (MSA) account to access or release funds during their lifetime, except for authorized expenses related to the original work injury covered by Medicare. This remains true even if an individual's condition improves.

Guidelines from CMS on Set-Aside Funds

The Centers for Medicare & Medicaid Services (CMS) does not allow the release or reduction of set-aside funds without its express approval. If a treating physician determines a beneficiary's condition has significantly improved, the beneficiary or their representative can submit a request to the appropriate CMS Regional Office (RO) for a reduction. This request must be accompanied by supporting documentation from the physician. The decision made by the RO is final and cannot be appealed.

Circumstances for Proposals to CMS

CMS outlines that if a new proposal is required due to significant health improvements, it must show at least a 25% reduction in the current WCMSA fund. Such proposals can only be submitted five years after a prior CMS approval and must include new supporting documents. If approved by CMS, any excess funds in the WCMSA may be released to the claimant.

WCMSA Account Restrictions

According to the WCMSA Reference Guide, funds in an MSA account can solely be used for medical treatments or prescriptions related to the work injury, which Medicare would otherwise cover. Unused funds at the end of a year are carried over to the next year, continuing until all funds are used appropriately.

In summary, while condition improvement may seem like grounds for reducing an MSA, CMS controls decisions about these funds, allowing access only for medical expenses related to the claim and covered by Medicare, irrespective of any health improvements the individual might experience.

For further details, please refer to the CMS.gov WCMSA Reference Guide.

Unused funds at the end of the year will not go to waste. Instead, they will remain in your account and automatically roll over into the next year.

How Do Unused Funds Roll Over?

When you have remaining funds, these are carried forward, allowing you to continue utilizing them in the future. There is no penalty for not using all of your funds within the current year.

Is There a Limit on Rollover Funds?

There is typically no limit to the amount that can roll over, but it can vary depending on specific account terms. It’s important to review your account details or contact your account provider for specifics about rollover limits or restrictions.

Need More Information?

For more detailed information on unused funds and account specifics, you may want to consult the official guidelines provided by your account service or reach out to customer support for tailored guidance.

Unused Medicare Set-Aside (MSA) funds remain in the MSA account and are carried over to subsequent years. These funds are reserved to cover medical treatment related to the claimant's workers’ compensation claim which Medicare would otherwise cover.

Carrying Forward Unused MSA Funds

According to the Centers for Medicare & Medicaid Services Self Administration Toolkit, if any funds are left over at the end of a year, they do not vanish. These remaining funds carry over to the next year, allowing usage of both the new annual deposit and the previous year's leftover amount. This continuous rollover ensures that all accumulated funds are used appropriately.

Post-Claimant Death Fund Management

In the event of the claimant's passing, if unused MSA funds remain, CMS may require reimbursement for any outstanding covered medical expenses. Medical providers have up to 12 months from the date of service to bill. Once all obligations to Medicare are cleared, the remaining MSA funds can be disbursed according to state law and the specific settlement agreement, potentially holding the account open for a period post-death.

For more detailed guidance, please refer to the Workers’ Compensation Medicare Set-Aside Reference Guide, v3.1 and the Self Administration Toolkit, v1.3. These resources cover comprehensive information on managing MSA accounts and handling funds responsibly.

If you do not properly manage your MSA account, you could severely jeopardize Medicare paying for your future medical care. Consequences include: denial of future bills from Medicare if your funds exhaust and being required to repay your MSA account for expenses that were paid for that are not covered by Medicare. Medicare reserves the right to have reporting for up to the entire settlement amount on medicare covered treatments before Medicare agrees to begin covering injury-related bills.

If the injured party doesn’t properly manage their MSA account, Medicare will deny paying for their injury-related treatment until the reporting is corrected. To do so, the injured party will have to pay back any amount that was used on an improper expense not relating to their injury back into the MSA account.

Mismanaging the MSA account will jeopardize the injured party’s future Medicare benefits; for this reason, it's important to be careful and seek assistance. Medicare "highly recommends" the use of a professional administrator.